The system of medicine for profit has gone into crisis in the
US. The increasing difficulty people have financing health care has
reached the point of a crisis. Not only are there almost fifty million
people uninsured, but tens of millions more of insured people find that
they can't get care when they need it. For example, a recent study by
the California Nurses Association shows that California health insurers
deny more than one out of every five medical procedures which doctors
prescribe for their patients, and this has resulted in the death of a
number of insured patients. (See "California's Real Death Panels:
Insurers Deny 21% of Claims: PacificCare's Denials j40%, Cigna's 33% in
First Half of 2009", www.calnurses.org/media-center/press-releases/2009/september/california-s-real-death-panels-insurers-deny-21-of-claims.html.)

This growing crisis is the background for the health care
debate that has broken out over Obama's proposal to make mainly
private health insurance universal. There are so many
different proposals, and
some of the proposals are so complicated, that it's easy to get bogged
down in a mass of details. To avoid this, I will concentrate on the
class issues and general principles involved in the different health
care proposals, rather than a mass of details. In the discussion
afterwards, people can bring up any of the points for more elaboration.

And indeed, health care is a class issue. That
millions of people
in the US who can't get adequate health care is an example of the
brutality with which free-market principles bear down on the working
class, and doubly so on the poor and the minorities. Health care is big
business in the US, and it has some of the most profitable
companies
around. But the profits of the health industry go hand-in-hand with
medical crisis for the masses.

It's a class question, not a matter that nobody knows how to
provide health care for an entire country. If providing health care
were
just a technical matter, it would have been provided to everyone in
this
country a long time ago. The fact is that most wealthy industrial
countries do much better at providing health care to most of their
inhabitants than does the US. From the relatively
simple national
health service in Britain and single-payer or government insurance
in Canada to complicated hybrid systems of universal care in
France and
Germany, to Japan, Taiwan, and various other countries, health
care is
provided for almost everyone. Not surprisingly, the US doesn't fare
particularly well in health statistics compared to other rich
countries, but the US is far and away the leader in the
amount of profits flowing
to the health industries.

It's not that the foreign systems of universal health care
don't
have their problems. They do. The bourgeoisie in those countries as
well
as the US is in love with market fundamentalism, and is seeking to pare
down the social programs of the past. But it is the American position
as
the foremost market-fundamentalist power, and the fanatic adherence of
the American bourgeoisie to market fundamentalism, that has led to the
health care crisis here. Single-payer health insurance, such as that in
Canada, would do away with most of private medical insurance, and the
American bourgeoisie won't hear of that. A system similar to the
National Health Service in Britain would also do this. Even the
complicated hybrid schemes in various European countries, while using
private insurance as part of their plan, regulate the insurance so
stiffly that it would look like a government program to an American
capitalist.

When we look at what the Republicans and Democrats
are
proposing, we will see that the problem is this: the insistence of the
politicians, in service to the bourgeoisie, on maintaining the profits
of the private insurers and other health industries, and their
insistence on maintaining deregulation, privatization, and market
methods. The neo-liberals pretend that we will get health care, not
through extending entitlements like Medicare to the entire population,
but through everyone going on the market and trying to find private
insurance. This is what is blocking health care reform.

Let's review the different standpoints of the Republicans and
Democrats.

The conservative Republicans and the "teabaggers"

Let's start with the conservative Republicans. They have been
shouting and screaming against the idea of health care reform, and have
organized the "teabaggers" to go around and rant against Obama and his
proposals. The conservatives and teabaggers have even descended into
crude racist taunts at Obama, as well as presenting him as a Hitlerite,
and one poll shows that 8% of the people in New Jersey believe that
Obama is the "anti-Christ". According to this poll, among those who
identify themselves as conservatives, 18% think Obama is the
anti-Christ, and another 17% aren't sure about the matter.

Now, behind all this mindlessness and hatred for Obama, what
are
they advocating? It's that the present system is fine, and it should be
perfected by just freeing up the capitalists a little more,
deregulating
a little more, and everyone will be happy. This is what the teabaggers
mean when they shout against government interference in health care.

And along those lines, the main Republican plan in Congress
consists of

A) curbing malpractice suits. This is supposed to be the cause
of high
medical prices. But various states have already done this, such as
California and Texas, and it hasn't made much difference to medical
costs.

B) allowing people to buy out-of-state private insurance. The
conservatives want this because it would free up insurance from state
regulation. But it wouldn't solve anything for people wanting health
insurance. Since there isn't any state where the private insurers are
doing a good job, having people buy a crappy out-of-state plan wouldn't
be any better than buying a crappy in-state plan.

C) removing all regulations on the insurers and the health
industries.
There are articles and books presenting deregulation as
"consumer-centered" care, although it would really mean unrestricted
profit-centered care. They claim that the health crisis stems from an
insufficiently free market. Sometimes this can reach extremes. The
table next to us at the Dally in the Alley was that of the Ron Paul
people, and their so-called "campaign for liberty". The man I spoke to
advocated that a true free market in health care would mean, not just
no
Medicare and no government health programs, but not even private
insurance. Even private insurance was supposed to distort the health
market.

These plans are delusional. It's like lemmings marching to the
sea. The free-market plans would, indeed, help the health capitalists
do whatever they want, but the health care crisis for the masses would
get
worse and worse. The only credibility that this mindless and fanatic
conservative agitation has is that it plays on people's legitimate
fears
that Obama's plan would result in cutting some of their present health
care coverage. As we shall see later on, there is a point to these
fears, but trying to fight these fears by joining the teabaggers is
jumping out of the frying pan into the fire.

Obama's plan

So this brings us to the Obama plan. Since the teabaggers
denounce him as a "big government" man, a socialist, and so forth, one
might imagine that he really is a radical, and that he wants major
change. Nothing of the sort. In fact, his plan is to maintain the
system
of private insurance that is the problem, and to bail out marketplace
medicine with some government help. Just like his bail-out of the banks
was not a socialist step against financiers, but a way to keep the
bankers solvent, so his plans for the health care industry are not a
socialist step against the private insurers and the pharmaceutical
companies, but an attempt to keep them happy. In fact he has been
playing footsy with them, meeting with them to arrange the details of
the plan, promising them major concessions, and so forth.

Obama's idea is to solve the problem of universal coverage by
forcing everyone to buy private insurance. The lack of logic of this
plan shows the desperate fanaticism by which the bourgeoisie clings to
market principles. Problem: people can't afford to buy private
insurance; supposed solution: to require them to do what they
cannot
afford to do. This logic may, of course, meet the approval of the
private insurers, who are rubbing their hands at tens of
millions more
policies financed by government subsidy, but it's not going to work.

Obama believes that he can square the circle, and have
everyone
buy private insurance, by giving subsidies to those who are in poverty.
And, he thinks, he can find a good deal of the money to finance these
subsidies by taking money away from one part of the health
system and
giving it to another. Later on I will go into who is going to lose
under
the Obama plan, but for now, let's just say that it is fantasy
health
care, a worthy successor of Ronald Reagan's voodoo economics.

The fact is that various states have already tried to solve
the
health crisis in the way Obama proposes. Currently, the model is the
Massachusetts, where everyone is supposed to buy private health
insurance or they're penalized. Those who can't afford insurance are
supposed to be subsidized, except that immigrants are treated badly.
I've brought to this meeting a 2009 report on the results of the
Massachusetts plan ("Massachusetts' Plan: A Failed Model for Health
Care
Reform", February 18, 2009,
www.pnhp.org/mass_report/mass_report_Final.pdf).
It shows that, despite
the legal requirement for universal insurance, the plan
hasn't provided universal coverage. True, there are more
people insured under this plan
than before, but unfortunately there is also a higher percentage of
people who can't afford health care even though they are insured. In
order for Massachusetts to provide affordable private plans to people,
the private plans are often so meager as to be painful themselves. For
example, many of the new private plans may have a $2,000 deductible, to
say nothing of the various co-pays. We also have available at this
meeting the August 2007 issue of Communist Voice
which describes the Massachusetts plan (see www.communistvoice.org/40cMass.html).

The fact is that Oregon, Minnesota, Tennessee, Vermont,
Washington, and Maine have also tried variants of the plan of
making
private insurance universal, while subsidizing those who can't afford
it. None of them have achieved universal coverage, and the document on
the Massachusetts plan that I've brought to this meeting has graphs
documenting the failure in these states. The usual result is that,
after
a while, the state finds that it is spending huge amounts of money and
has to cut back its plan. The most recent fiasco was that of the
collapse of TennCare, the plan whereby Tennessee moved people from
Medicaid by putting them into privately-managed care programs.
Eventually all of the private companies dropped out of the program and
the state was left holding the bag.

The class basis of all these plans is that they are an attempt
to
solve the problem while leaving the profits of the private insurers and
the health care industry untouched, and while continuing the path of
privatizing government programs. No matter how much these plans flop,
there is always a new one being promoted, because the bourgeoisie still
believes in neo-liberalism. It will require the smash-up of
neo-liberalism, and the mass pressure of the working class, to bring
something new to the health care debate. And then it will be found
quite
possible to provide universal, quality care.

Tired-out principles of privatized coverage

Meanwhile, Obama's framework for a health plan follows the
same
tired old neo-liberal principles. It's based on the following ideas:

* There shouldn't be a new government
entitlement, whereby people are
guaranteed a certain level of health care, as Medicare somewhat does.
Instead, people are to be mandated by law to find private insurance;
and
this insurance, especially for the poor, will be very spotty. Help may
be given to those who can't afford the mandate — depending on who's in
power and what the government budget is like — but in the final
analysis, the individual is to be penalized if there is a problem.

* The private insurers, the pharmaceutical
companies, and the hospital
capitalists are too big to fail.

* The subsidies to individuals will, in
effect, be subsidies to the private insurance companies.

* Employer-based insurance will be
continued, thus keeping workers' health coverage tied to the health of
their companies and the workers'
ability to resist cutbacks. Workers will have to fight
employer-by-employer over the extent of their benefits, and this is
very
difficult in the current great recession.

* The program will be revenue-neutral; that
is, much of the cost for
extending private insurance to more people will be borne by taking
money
away from other aspects of health care.

* Medical reform will be driven mainly by
cost control over how much
medical care is provided, and will have nothing to do with either
restructuring the health industries, eliminating private insurance, or
mass involvement in the orientation of medicine.

Yet at the same time, Obama promises that those who can't
afford health
care will be subsidized, that people will be able to transfer their
health care from one insurer to another, and that there will be no
exclusions for prior conditions. But how can he accomplish this, while
implementing his principles? How can he avoid the problems that
affected
all the states that tried to do these things?

He can't. The attempt to do has resulted in a plan that is
monstrously
complex and involved. The House health care bill is over 1,000 pages.
And it is reported that it schedules the implementation of this or that
measure over a time period taking up to a decade. Right there, that
should be a giveaway that something's wrong. Thus it isn't supposed to
be until 2013, after the next presidential election, that the Health
Exchanges are to opened, the Health Exchanges being where uninsured
oeople are supposed to get their coverage. And other features of the
plan would wait still more years to be put in place. An Afro-American
political website, "The Black Agenda Report", commented acidly on this
timing that Medicare, put into practice in the mid-1960s, managed to be
up and running in eleven months, while today, in the age of computers,
the Obama plan would take a decade ("Is the Obama Health Care Plan
Really Better Than Nothing?",
www.blackagendareport.com/?q=content/obama-health-care-plan-really-better-nothing).

This complexity reflects the difficulty in finding any way to
extend private insurance to all, and it also reflects a deadlock
between
different capitalist interests — those of private insurers, hospitals,
states with their Medicaid budgets, etc. — over what to do.
But it's
also true that this complexity is itself a class issue. It helps the
bourgeoisie, much of which can profit handsomely over a complex plan,
while hurting ordinary people who are left bewildered.

When a bill's so complex, and when there are so many different
programs and subsidies and exceptions and subclauses that differentiate
the care one person will get from what another person will get, it
divides up the population, and makes it hard for the masses to fight
for
their rights.

And the more complex a bill, the more room there will be for
high-paid managerial consultants, lawyers to interpret the bill, and so
forth. There will be more and more money for bourgeois and
administrative positions, and less and less for health care.

Squeezing the young, the old, unionized workers, immigrants,
and
women

Finally, it can be noted that Obama, while seeking to
conciliate and bribe off just about every capitalist interest
involved, has made
the plan repulsive to may people. This is the result of his
revenue-neutral pledge. Many natural constituents for health
care
reform, who might otherwise come out on the street demanding health
care
reform, face the possibility that Obama's plan, to this or that extent,
will hurt them. This, as I mentioned before, is being exploited by the
teabaggers for their own stupid, mindless, racist, and
nefarious
interests, but we do have to recognize that there's a real issue here.

Let's look at some examples.

Obama raised the possibility of taxing so-called "gold-plated"
employer-paid medical plans. But workers fought hard to get
employer-paid benefits. It would be one thing to replace these benefits
by a national or government plan: that would be an advance that would
separate workers' health from their employers' whims. But to insist
that these benefits be cut back, and to finger some of these benefits
as the
alleged cause of the high cost of medical care, is outrageous. The
attack on "gold-plated plans" suggests that Obama thinks that
cost-cutting should be accomplished by keeping insurance plans so
filled
with limitations and co-pays and deductibles that getting medical care
would remain so financially painful that workers will shy away from
using very much of it.

Obama would also finance the plan, in part, by massive cost
savings in Medicare. He claims that this can be achieved by cutting
reimbursements to doctors and to the HMOs who run the Medicare
Advantage plans, which are a privatized section of Medicare. But it's
hard to see
how these cutbacks can be made without, in fact, cutting medical
benefits. If Obama proposed to eliminate Medicare Advantage and replace
it by extending Medicare benefits, that would be one thing. But to
threaten the benefits many seniors already have is an entirely
different thing.

The Obama plan stresses the need to enroll young adults, not
for
the sake of their health, but as a way of helping the private insurance
companies keep down premiums for older workers. And on top of this,
special plans for students and young workers are envisioned which would
give minimum benefits, just as is presently done, by the way, in
Massachusetts. Thus these plans make youth one of the villains of the
drama, while the real villains are the corporate profiteers.

In his major speech of Sept. 9, Obama stressed that his plan
would not give a penny to help undocumented immigrants. This means that
his plan would leave out many workers in the direst need of help, and
does not really aspire to be universal health care. This also helps
alienate the large section of workers who are closely connected to the
undocumented immigrants and concerned about them.

Obama also pledges that no federal money would be used to
cover abortions. Does this mean that people who get subsidies
under Obama's
plan couldn't use their subsidy to buy a health plan that covers
abortions, or does it mean that all private plans would have to drop
coverage for abortion in order to be part of the Obama plan? Who knows?
But whatever the answer, it's clear that Obama's betrayal of women's
rights will hurt women's health care.

Thus workers, seniors (with their experience of Medicare), and
young people, who should be enthusiastic backers of national health
care, are made into targets of the plan, and all of them have reason to
worry about what type of medical care they will be provided. Similarly,
the Latino population will face pressure from the anti-immigrant
provisions of the bill, while women are treated callously.

Thus the reality of the Obama plan conflicts with its promise
of
universal health care.

Alternatives, real (single-payer) and apparent (the public
option)

It's no wonder that the Obama plan has gathered opposition
even
from some Democrats. So what is the alternative? A section of
Democratic
liberals are insisting that Obama make good on the promise for a public
option, which would serve as an alternative to private insurance. This
is the main issue the liberals are fighting on. However, the public
option really wouldn't change the Obama plan very much. It was never
intended to cover a large number of people: it wasn't supposed to be
available to everyone. Moreover, it is being insisted that the public
option would be run in the same way as a private insurance company,
except maybe as a co-op. This would mean that it really wouldn't be
that
different from the private insurers.

Meanwhile, a section of the liberal Democrats talk about
"single-payer health insurance", such as the plan put forward by the
Conyers bill, HR 676. These plans would be roughly similar to the
system
used in Canada. They would not make private health insurance universal,
but would eliminate most private health insurance. Instead, the
government would pay the bills for the medical work authorized under
this plan. It would be something of an extension of Medicare to the
entire population.

This is a real alternative. "Single-payer" health
insurance
would be a major advance. It would provide universal health care
(provided all immigrants are included, as they are in the present
version of HR 676); by its very nature, it would eliminate the worry
about preexisting conditions; and it would also eliminate all worries
about portability, since one would be covered anywhere in the country.
It would manage health care more efficiently than private insurance,
and
cut out the huge overhead and administrative costs of private
insurance.

This would be a real change in the health care system and a
gigantic step forward. It is feasible, as its existence in Canada
shows.
It's simple and straightforward, and it puts everyone in the same
category, which by itself is a certain guarantee against some types of
abuses. It does all this by going against market fundamentalism — by
making health care into an entitlement, and replacing private insurance
by a government program. It is a reasonable plan and technically
feasible; and it's reasonable and feasible only because it sins
against
market fundamentalism and takes one aspect of health care out of the
reach of financiers and corporate CEOs.

Does this mean single-payer health insurance is socialism? No
doubt it is in the eyes of the teabaggers. But, unfortunately, it is
not
socialism, but only a reversion to the capitalist "mixed economy",
which
was the theory preceding market fundamentalism. It's no more socialism
than public libraries, public schools, the fire department, and the
public water supply are socialism. Capitalism always makes use
of the
government to provide for services which can't be provided by the free
market; and the bourgeoisie swings back and forth between using more or
less regulation, more or less government intervention. It is in the
interest of the working class that health care be regarded as a right
of
every citizen and that health insurance be turned into a government
function; but that doesn't mean we should be under any illusions about
health care becoming socialist simply because the government pays for
it.

Meanwhile, Conyers and the congressional backers of
"single-payer"
aren't pressing very hard for it, since as Democrats they are beholden
to the bourgeoisie and they know the bourgeoisie still isn't willing to
go for it. Moreover, Conyers and other single-payer advocates usually
obscure the class issues surrounding a change to single-payer health
insurance.

For example, it is often presented that the change to
single-payer would be easy, since there is no major technical obstacle
to implementing a single-payer system. But the obstacles to
implementing
single-payer aren't mainly technical; they're based in the class
interests of the bourgeoisie. Not only is the bourgeoisie as a whole
still insisting on market solutions to everything, but over the last
few
decades the health industries have grown into extremely powerful
financial interests. Consider the big insurers and HMOs, the
big
pharmaceutical companies, the medical suppliers, and the
increasingly-corporatized hospitals. They are influential, and they
will
oppose any plan that eliminates them, as the private insurers will be
under single-payer, or restricts them.

Even back in the 60s in Canada, when single-payer came up, it
took more than convincing the people of its desirability. It took
standing up to opposition. Single-payer was first introduced in the
Canadian province of Saskatchewan by the Cooperative Commonwealth
Federation government of Tommy Douglas (the CCF was the predecessor of
today's flabby New Democratic Party). It was immediately met by a
doctors'
strike, which failed due to lack of popular support. One might expect
that, today in the US, the opposition of fabulously wealth
insurers and
other health corporation interests to single-payer insurance
would be
much more fierce than that of the Saskatchewan doctors of the 1960s.

Moreover, it will be important for the working class to be
vigilant about how new government programs, even a single-payer
program,
are carried out. Neo-liberalism, or market fundamentalism, isn't the
only form of capitalism. When the bourgeoisie, faced by economic and
environmental crises, turns back from market fundamentalism to the
theory of the "mixed economy", it will be important to see that this
is
not a turn to socialism, but only an adjustment in capitalism. It will
be important for the working class to keep up mass pressure on the
government regulations and government programs that are established,
including health programs. Single-payer health insurance, or
even a national health service, would not be
the end of the struggle over
health care.

If we want to be sure that all immigrants are covered by
health
insurance, we can't simply rely on the fact that the present draft of
the Conyers Bill covers all residents. It will be necessary for the
working class to organize and protest in defense of the immigrants,
including the undocumented immigrants..

If we want health care to include abortion rights and
contraceptive information, the working class had better be vigilant on
this question. The conservatives who today organize teabaggers, and the
corporate interests who fund them, won't go away in the future, but
will
continue to push reactionary ideas.

If we want to ensure that health care reform and cost-cutting
doesn't mean restricting treatment for workers and the poor, but
instead
means restructuring the health care industries, curbing corporate
profiteering, eliminating the bad health care practices
fostered by the
big pharmaceutical companies, and so on, the working class is going to
have to get organized in its own right.

Indeed, let's not forget that many advances in health care
have
come about because of mass influence. The large mass movements of the
60s pushed, not just for better funding of health care, but for better
health care practices. It was the women's movement and pro-choice
movement that not only fought for reproductive rights, but for more
attention to women's health issues from breast cancer and menopause to
assessing the differences in how medications and other treatments
affect
women and men. The black people's movement persisted in pushing for the
issue of the sickle cell trait to be taken seriously. Gay people fought
tor attention to be paid to AIDS. And the general movements against
racism and sexism have had a lot to do with bringing more minorities
and
women into the ranks of doctors. Moreover, the overall atmosphere
created by the mass struggles of the time resulted in eliminating a bit
of the elitism and arrogance manifested by some doctors. Reforms like
"single-payer", however important, don't do this in and of themselves;
mass pressure is required. It is the mass struggle, and not
deregulation
or choosing between one or the other over-priced private
health plan,
that will bring people- centered medicine.

So long as capitalism exists, there will always be need for
this
mass pressure, and the capitalists will seek to take back the
concessions they make on universal health care and other issues. This
can be seen if one examines the state of the European and Canadian
health care systems which, while superior to the US system, are
susceptible to neo-liberal cutbacks, and to being starved of funds. It
is constant pressure from the working population of these countries
that
prevents these plans from being dismantled.

Socialist health care

Socialist health care is something that will exist only under
socialism, when the workers are in control. It will resemble the best
capitalist plans in being universal health care. But it will remove the
profit motive not just from health insurance, but from all the health
industries. And because the workers will take over the running of the
entire economy, it will be possible to integrate health care more
closely with taking care of workplace injuries, with providing
guidelines to make the workplaces safer, with keeping track of the
dangers of new chemicals, new products, and new innovations, and so
forth.

Socialist health care will also differ from capitalist health
care in radically curbing the elitism that persists in the present
health professions. While there will always be a need for
specially-trained medical personnel and doctors, the entire structure
and ideology of a socialist system will provide a closer integration of
ordinary workers and medical personnel, and more room for the masses of
people to influence the practice of medicine. Also, as part of
the
general linking mental and manual labor under socialism, a closer
collaboration of medical professionals will replace the present vast
gulf between doctors, nurses, and other health workers. The financial
reasons for maintaining this elitism in health care, which operate
powerfully under capitalism, will no longer exist under socialism.

Health care is a class question

Summing up, the present health care debate has become obscure
because of the mass of details. But underneath the
complexities of the health
care problem, we can see some basic issues:

* It is not a technical problem to
introduce universal health
care, it is a class problem: the issue of overcoming market fanaticism.
The market-fundamentalist bourgeoisie doesn't believe the
working class
has any right to health care or anything else, and powerful
corporate
interests in medicine would be harmed by government health plans.

* We can also see that there is
going to be a long fight on the
issue of health care, even after the achievement of
single-payer health
insurance, and even if Medicare were extended to everyone. That's
because the high cost of health care, and the very treatments
prescribed
by doctors and others, are affected by the corporate interests such as
the large pharmaceutical companies.

* Even though some capitalist interests may
back this or that
reform in order to get out from the burden of high medical costs, it is
only the working class that will fight wholeheartedly for universal
health care.

* And neither the
Republican fanatics nor the Democratic Obama
administration are on the side of the working class. Both the
teabaggers
and Obama, each in their own way, back market solutions and link up
with
various corporate interests. It is up to us to build an independent
working-class movement, and to have this movement intervene as strongly
as possible in the debate on health care. <>